One in eight. That is how often an epidural in labour doesn't reduce the pain enough — so that you need other ways of coping — according to the epidural information card published by the Obstetric Anaesthetists' Association (OAA). The figure sits oddly with the epidural's reputation as the one form of pain relief that simply works — and the NHS itself says that "In most cases, an epidural gives complete pain relief". Both things are true at once. The same NHS page adds that "it's not always completely effective in labour".
There is a second surprise, and it comes from how UK maternity care is organised. An epidural is only available in an obstetric unit — if you're labouring at home or in a midwife-led birth centre, getting one means a transfer. None of this makes the epidural a poor choice. It means the version most of us carry in our heads (a switch that turns the pain off) needs updating. Here is what really happens, from asking to relief, and what else is on offer.
What is an epidural, exactly?
An epidural is a form of regional anaesthesia. Medicine is given close to the nerves that carry pain from the womb (uterus), numbing the pain of contractions — without putting you to sleep. The anaesthetist places a needle in your lower back and uses it to thread a very thin tube (the epidural catheter) near the nerves in your spine. Then the needle comes out. The catheter stays in for the rest of labour, and that is how the pain relief keeps flowing, dose after dose.
What goes down that tube has changed over the years. The NICE guideline on intrapartum care (NG235, 2023) recommends a low-concentration local anaesthetic combined with an opioid such as fentanyl (a strong painkiller) — and advises against high concentrations as a routine. The Cochrane review of epidurals in labour explains why this matters: lower concentrations, given with an opiate, let women keep moving around and take an active part in the birth.
Three related techniques sit under the same word:
- An epidural — the catheter stays in your back, so it can be topped up for as long as labour lasts.
- A spinal — a one-off injection, without a catheter, into the bag of fluid around the nerves. It works much faster, but it can't be topped up.
- A combined spinal-epidural (CSE) — both at once: a spinal for quick relief, then a catheter to keep it going. NICE recommends a CSE when rapid pain relief is needed.
You'll often hear midwives and anaesthetists call all of these "regional analgesia". It's the phrase you'll see in your notes.
Before labour: planning ahead and when to ask
The best time to find out whether you can have an epidural is before labour starts. That's the advice in the OAA's frequently asked questions on pain relief in labour. If you have a back condition, a previous back operation or a clotting problem, mention it to your midwife early in pregnancy. She can arrange for you to talk it through with an anaesthetist before the day.
Where you plan to give birth matters more than people expect. The NHS puts it plainly: "An anaesthetist is the only person who can give an epidural, so it will not be available at home." NICE adds that epidurals are only available in obstetric units, so a transfer is needed from any other setting. If you're booked into a birth centre and think you might want one, it's worth knowing how transfers work there — and the NHS suggests checking whether anaesthetists are always available at your hospital.
NICE simply says that if a woman requests an epidural, her team should talk through the benefits and risks with her — and support her decision. Timing still matters in practice. The OAA puts the whole process at about 40 minutes, from the start of the procedure to feeling the effect, and notes that epidurals are rather slow to act late in labour. That is when a spinal or a CSE comes in (both work faster).
Having an epidural, minute by minute
An epidural usually takes about 20 minutes to set up and another 20 minutes to work, according to the OAA. The NHS gives a slightly quicker estimate — about 10 minutes to set up, and 10 to 15 minutes to take effect. Here is what happens, step by step.
- Minute 0 — you ask. You tell your midwife you'd like an epidural. She calls the anaesthetist, who talks you through the benefits and risks.
- The cannula. A fine plastic tube goes into a vein in your hand or arm — NICE says this must always be in place before regional analgesia starts. You'll usually have a drip running too.
- Your position. You either curl up on your side or sit on the edge of the bed, leaning forwards (your midwife will help you into position).
- Cleaning and numbing. The anaesthetist cleans your back with antiseptic, then injects local anaesthetic into the skin — which is why putting in the epidural does not usually hurt much, says the OAA.
- The needle and the catheter. The needle goes in, the catheter is threaded through it, and the needle is removed. This is when keeping still matters most.
- Taping it down. The catheter is fixed in place with tape. From here on, you're free to move.
- The first dose — a test dose. NICE describes the first dose as "essentially a test dose", given cautiously to check the catheter is in the right place.
- Close monitoring. For the first 15 minutes, NICE advises measuring your blood pressure every 5 minutes. Your baby's heart rate is monitored continuously for at least 30 minutes.
- The cold test. The anaesthetist often puts an ice cube or cold spray on your tummy and legs, and asks how cold it feels — a quick way to check the right nerves are numb.
- Around minute 40 — relief. The OAA card says an epidural usually provides excellent pain relief. If you're not pain-free 30 minutes after a dose, NICE says the anaesthetist should review it.
During labour: top-ups, moving and monitoring
Once the epidural is in, the pain relief has to be kept going. NICE lists three ways of doing it: a patient-controlled pump (PCEA), a pump that gives programmed doses at set intervals (a programmed intermittent bolus), or top-ups given by a trained midwife. With a PCEA, you press a button when you need more — and each unit will usually offer just one or two of these options, says the OAA. After each top-up, your blood pressure is checked again.
Can you move? Often, yes. Since 2023, NICE advises that if your legs have enough strength and feeling — checked by a midwife trained in epidural care — you can get up and move with help, though your legs may feel heavier than usual. NICE also encourages any position you find comfortable, upright ones included, with one exception: lying flat on your back. So-called mobile epidurals exist too, but the NHS points out they need your baby's heart rate monitored remotely (telemetry) — and "many hospitals do not have the equipment to do this".
The checks then settle into a rhythm. Every hour, the midwife assesses how numb you are and, if you're not walking about, asks you to lift a straight leg. None of this means something is wrong — it's simply what caring for someone with an epidural looks like.
Should the epidural be switched off so you can push? Not routinely. Once established, NICE says regional analgesia should continue until after the placenta is delivered and any stitches are done. Some teams do reduce the dose near the end so you can feel to push, the NHS notes. It's a conversation worth having with your midwife.
Who can't have an epidural?
Most women can have an epidural. The OAA's answer is short and worth quoting in full: "Most people can have an epidural, but certain medical problems (such as spina bifida, a previous operation on your back or problems with blood clotting) may mean that it is not suitable for you." In practice, that gives three situations to flag early:
- Spina bifida — a condition of the spine present from birth.
- A previous back operation — whatever it was for, mention it.
- A blood-clotting problem — a known disorder, or medication that affects clotting.
Being overweight doesn't rule an epidural out. The OAA says an epidural may be more difficult and take longer to put in — but once it's in and working, you get all the benefits. And the simplest reason of all needs no justification — you may just not want one.
Epidural side effects, in numbers
Epidural side effects fall into two groups — the common and short-lived, and the rare but serious. The Cochrane review of epidurals for pain relief in labour (2018, 40 trials, over 11,000 women) describes the first group. Compared with women given opioids, women with epidurals had more low blood pressure, more temporary leg weakness (motor block), more fever and more trouble passing urine. They had less nausea and vomiting, though, and no clear difference in headache, itching, shivering or postnatal depression.
The OAA card puts rough odds on both groups. It adds a fair warning: "The figures shown above are estimates and may be different in different hospitals."
| Risk | How often | How the OAA describes it |
|---|---|---|
| Significant drop in blood pressure | 1 in 50 women | Occasional |
| Not working well enough, other pain relief needed | 1 in 8 women | Common |
| Not working well enough for a caesarean (general anaesthetic needed) | 1 in 20 women | Sometimes |
| Severe headache | 1 in 100 women | Uncommon |
| Temporary nerve damage (numb patch, weak leg) | 1 in 1,000 women | Rare |
| Nerve damage lasting more than 6 months | 1 in 13,000 women | Rare |
| Epidural abscess (infection) | 1 in 50,000 women | Very rare |
| Meningitis | 1 in 100,000 women | Very rare |
| Epidural haematoma (blood clot) | 1 in 170,000 women | Very rare |
| Severe injury, including paralysis | 1 in 250,000 women | Extremely rare |
The NHS adds some everyday detail. Your legs may feel heavy, depending on the local anaesthetic used. Your blood pressure can drop, but this is rare because the fluid from your drip helps to keep it up. You may find it hard to pee — a small tube (catheter) can be put into your bladder to help. And about 1 in 2,000 women feel tingling or pins and needles down one leg after the birth, which the NHS says is more likely to come from childbirth itself than from the epidural.
The last line of the table is the one that frightens people most — and it's the rarest: one severe injury for every 250,000 epidurals.
Headache after an epidural and the blood patch
The post-dural puncture headache is the complication few people hear about beforehand. Your brain and spinal cord sit in a fluid-filled sac (the dura). If the epidural needle punctures it by accident, fluid leaks out and the pressure around the brain drops — and that pressure change causes the headache. The OAA leaflet on headache after an epidural or spinal puts the chance at between 1 in 100 and 1 in 200.
This headache has a signature. It starts in the days after the epidural. It's often severe. And, as the leaflet puts it, "It is worse on sitting up and better on lying down." You may also have neck pain, and bright light may be uncomfortable.
Treatment starts simply — bed rest, plenty of fluids including caffeinated drinks, regular painkillers (such as paracetamol or ibuprofen) and time. If it doesn't settle, or is very severe, the anaesthetist may offer a blood patch. A little blood is taken from a vein in your arm and injected into the epidural space, usually more than 24 hours after the puncture. As it clots, it seals the leak. You'll be asked to lie down for a few hours afterwards. About 1 in 5 blood patches don't stop the headache, so a second may be needed; the chance of another puncture is under 1%. Not every post-epidural headache needs a blood patch, the NHS adds — your anaesthetist will talk through the options.
Epidurals, forceps, caesareans and your baby: what the evidence says
Does an epidural make forceps or ventouse more likely? NICE's answer, in the information it asks midwives to give, is yes: an epidural "is associated with a longer second stage of labour and an increased chance of birth with forceps or ventouse". The Cochrane review qualifies this. Across all trials, assisted births were more common with epidurals (risk ratio 1.44). In trials run since 2005, that effect was no longer clear (1.19, not statistically significant). The authors think "this finding probably reflects the higher concentrations of local anaesthetics used traditionally rather than the low concentrations of modern epidurals".
On caesareans, the evidence is reassuring. NICE says an epidural "is not associated with a longer first stage of labour or an increased chance of an unplanned caesarean birth". Cochrane found no difference in caesarean rates (risk ratio 1.07, over 10,000 women) — and none in long-term backache either.
What does change is how you push. With an epidural, you may not feel the urge. NICE advises that, unless you feel the urge or the baby's head is visible, pushing may be delayed for up to 2 hours after full dilation in a first labour (1 hour if you've given birth before). The NHS explains the point of waiting — it reduces the chance you'll need an instrumental delivery. And since 2023, NICE notes that lying on your side to push with an epidural may increase the chance of a spontaneous vaginal birth.
And your baby? The OAA says an epidural will have hardly any effect on your baby. In the Cochrane review, admissions to neonatal intensive care and Apgar scores showed no clear difference, and fewer babies in the epidural group needed a drug to reverse opioids. On breastfeeding, the OAA is direct: "Having an epidural does not make it any harder to breastfeed."
If you end up needing a caesarean, an epidural already in place is a real advantage. It can usually be topped up for the operation, which often avoids a general anaesthetic — though in about 1 in 20 women it isn't strong enough. Our complete guide to planned and emergency caesareans explains what happens next.
When the epidural isn't working well enough
An epidural that doesn't fully work is not unusual — and it's not a failure on your part. The OAA card puts it at 1 in 8 women needing other ways of lessening the pain, and the FAQ explains what usually happens next. Sometimes the epidural doesn't work well at first, and the anaesthetist adjusts it — or takes the catheter out and puts it in again.
Most of these situations can be put right. It all depends on one thing: the team knowing you're in pain. If the pain is still there 30 minutes after a dose, NICE says the anaesthetist should come back and review it.
The stitches deserve a mention too. If you need a tear or episiotomy repaired, NICE says the team should make sure effective pain relief is in place first — topping up the epidural or giving a spinal if necessary. It goes further: "If the woman reports inadequate pain relief at any point, address this immediately."
Alternatives to an epidural on the NHS
NHS maternity units offer several kinds of pain relief besides the epidural, and the NHS guide to pain relief in labour walks through each one. Gas and air (Entonox) is the most familiar — a mixture of oxygen and nitrous oxide that you breathe through a mouthpiece you hold yourself. It takes 15 to 20 seconds to work, so you start breathing it just as a contraction begins. It won't remove all the pain, but it can make it more bearable. NICE says it may make you feel sick and light-headed.
Pethidine or diamorphine injections take about 20 minutes to work and last 2 to 4 hours. NICE is frank that they give limited pain relief, and can have significant side effects for you (drowsiness, nausea) and for your baby — including drowsiness that may make breastfeeding harder. Remifentanil is newer: an opioid (a strong painkiller) you give yourself through a vein by pressing a button. Since 2023, NICE has recommended it as an option in obstetric units, with a midwife with you throughout. Compared with pethidine, women using it are less likely to need an epidural or forceps — but more likely to need extra oxygen.
| Option | What it is | What the NHS and NICE say |
|---|---|---|
| Epidural | Local anaesthetic and opioid through a catheter | More effective pain relief than opioids (NICE) |
| Gas and air | Oxygen and nitrous oxide, breathed in | May reduce pain; can cause nausea and light-headedness |
| Pethidine, diamorphine | Injection into the thigh or buttock | Limited relief; side effects for mother and baby |
| Remifentanil PCA | Opioid through a drip, controlled by you | An option in obstetric units, with one-to-one care |
| Sterile water injections | Tiny injections in the lower back | For back pain: relief from 10 minutes, up to 3 hours |
| TENS | Mild electrical pulses through pads on the back | Very little evidence in established labour, no evidence of harm |
| Water | Labouring in a birth pool | Can help you relax; water no warmer than 37.5C |
Sterile water injections are one of the lesser-known options. Since 2023, NICE has recommended considering them for back pain in labour — tiny injections at four points in the lower back, given by a trained midwife. They can relieve back pain from 10 minutes after the injection for up to 3 hours, though they sting at first. TENS is another. NICE is candid: "TENS devices are not provided by the NHS", and there is very little evidence of their effectiveness in established labour — but no evidence of harm either. The NHS notes it works best in the early stages.
For the latent (early) phase, NICE advises that breathing exercises, a shower or bath and massage may all reduce pain. It does not recommend offering acupuncture, acupressure or hypnosis during labour — though if you want to use them, your midwife should support your choice. If you're hoping to give birth without an epidural, our guide to natural birth and how to prepare for it covers the techniques and the birth plan in detail.
After the birth: legs, bladder and back
After the birth, the epidural is stopped and the numbness wears off gradually. NICE gives a clear safety marker here, added in 2023: by 4 hours after the last dose, you should be able to lift a straight leg (the "straight leg raise" test). If you can't, the obstetric anaesthetist should review you urgently. Until your legs feel like yours again, don't get up without help.
If you struggle to pee, a catheter can drain your bladder until the feeling comes back. Your back may be a bit sore for a day or two where the epidural went in. Long-term backache, though, is not an epidural side effect. The NHS says epidurals do not cause long-term backache, and the OAA card spells it out in capitals: "Backache is NOT caused by epidurals but is common after any pregnancy." Cochrane found no difference either.
Frequently asked questions
Does having an epidural put in hurt?
Having an epidural put in does not usually hurt much, according to the Obstetric Anaesthetists' Association, because the anaesthetist numbs the skin with local anaesthetic first. For most women, the hardest part is keeping still through contractions — tell the anaesthetist when one is coming.
Is it ever too late to have an epidural?
Not necessarily. Epidurals are slow to act late in labour, so a spinal or a combined spinal-epidural — both faster — may be offered instead; NICE recommends a CSE when rapid pain relief is needed. Allow roughly 40 minutes from starting the procedure to feeling the effect.
Can an epidural cause paralysis?
Paralysis after an epidural is extremely rare. The OAA estimates the risk of severe injury, including paralysis, at 1 in 250,000 women. Temporary nerve damage (a numb patch or a weak leg) is more common, at about 1 in 1,000, and usually recovers.
Does an epidural affect the baby?
The OAA says an epidural will have hardly any effect on your baby. The 2018 Cochrane review found no clear difference in neonatal intensive care admissions or Apgar scores, and having an epidural doesn't make breastfeeding any harder.
Does an epidural increase the chance of a caesarean?
No. NICE says an epidural is not associated with an increased chance of an unplanned caesarean birth, and the Cochrane review found no difference in caesarean rates across more than 10,000 women. It is linked with a longer second stage and a higher chance of forceps or ventouse.
Can I have an epidural in a birth centre or at home?
No. Epidurals are only given in obstetric units, because an anaesthetist is needed. If you're labouring at home or in a midwife-led unit and decide you want one, you'll need to transfer to an obstetric unit first.
Sources
- NHS — Pain relief in labour
- NHS — Epidural: side effects
- NICE — Intrapartum care, guideline NG235 (2023)
- Obstetric Anaesthetists' Association — Epidural Information Card (2021)
- Obstetric Anaesthetists' Association — Frequently Asked Questions: Pain Relief During Labour
- Obstetric Anaesthetists' Association — Headache after an epidural or spinal injection (2016)
- Cochrane — Epidurals for pain relief in labour (2018)